Steps to successfully breastfeed the premature infant

The birth of a premature infant causes emotional upheaval for parents. They often wonder what they can do to help their infant during the critical newborn period. Providing breast milk is one of the most important physiologic benefits a mother can give her premature infant. The advantages of breast milk are numerous. It is the responsibility of those who care for premature infants and their families to provide parents with the support they need to supply the best possible nutrition for their infant. Breastfeeding a premature infant can challenge both the mother and her health care team, however. Infants should be assessed individually for readiness to proceed through the steps leading to successftil breastfeeding. From establishing a milk supply to putting the baby to the breast, parents rely on the nurse for information, instruction, and encouragement. This article identifies obstacles to breastfeeding the premature infant and offers a step-by-step approach for promoting successful breastfeeding in the NICU.     

Bottle‐feeding an infant feeding modality: An integrative literature review

Bottle‐feeding is an infant feeding modality that has been in existence since ancient times, and currently, a significant number of infants are being fed via a bottle with either breastmilk or formula. Although research on bottle‐feeding has continued, it exists in fragmented, often small studies that focus on singular aspects of feeding an infant using a bottle, with limited information on the bottle‐feeding act. Systems theory was the approach used to define the act of bottle‐feeding and identify the parts within this act. Health databases were searched using MeSH terms. A summary of the studies are included. The findings of this review revealed that healthy term bottle‐feeding infants use similar tongue and jaw movements, can create suction and sequentially use teat compression to obtain milk, with minimal differences in oxygen saturation and SSB patterns, when compared with breastfeeding infants. Bottle and teat characteristics were revealed to affect infant feeding and milk intake. An infant's milk intake during feeding was shown to have a strong association with the interaction between the infant and parent/caregiver. With the issue of who controls the feed, mother or infant, likely to affect an infant's ability to self‐regulate their milk intake. Redefining bottle‐feeding as a holistic system identifies the interrelationship of the various parts which will improve the understanding of the reciprocal nature of infant feeding. To optimize bottle‐feeding outcomes, further research is required on parents' and health professionals' knowledge and understanding of the parts within the act of bottle‐feeding.     

Mother's choice to provide breast milk and developmental outcome.

The association between a mother''s choice to provide breast milk and her baby''s developmental status at 18 months post term was investigated in 771 low birthweight infants from five centres. Babies whose mothers chose to provide milk had an 8 point advantage in mean Bayley mental developmental index over infants of mothers choosing not to do so. A 4.3 point advantage remained after adjusting for demographic and perinatal factors. A similar finding was derived using a fundamentally different and questionnaire based test (academic scale of Developmental Profile II). Whether this significant residual developmental advantage relates to parental factors or to a beneficial effect of human milk itself on brain development has important implications for the nutritional management of premature babies.     

Post-discharge nutrition for the preterm infant

Newly designed, 'enriched,' formulas are now available for the formula feeding premature infant after hospital discharge. These new formulations add to the array of milks from which to choose when the discharge of the premature infant is approaching. However, the data to support optimal or reference nutrient intakes to use for the premature infant in the post-discharge are lacking. Breastfeeding should be encouraged as its beneficial effects may be related to the duration in which it is fed. Infants at risk for growth failure in the post-discharge period, such as infants unable to consume ad libitum intakes of milk, and who already have growth faltering or abnormal nutritional indices, may benefit for the addition of enriched formula. This review summarizes the recent data and comments on recommendations on post-discharge nutrition for premature infants.     

Relactation by mothers of sick and premature infants

Relactation, the induction of lactation at any time beyond the immediate postpartum period, has received minimal scientific investigation. In this study, one adoptive mother and six mothers ten to 150 days postpartum, who for a variety of reasons did not initiate or maintain lactation after delivery, attempted relactation. Each suckled her infant at regular feeding intervals. Prior to milk production, formula was provided during suckling through an artificial device. Serum prolactin responses to thyrotropin-releasing hormone infusion and to suckling were measured at the start of the study and to suckling at approximately weekly intervals thereafter. All mothers produced milk; three completely nourished their infants and two others provided at least half of their infants' nutritional needs. The adoptive mother and one other failed to provide significant quantities of milk. Mothers reached their maximum potential for milk production in varying periods of time (eight to 58 days). Shorter postpartum interval and less postpartum breast involution correlated with the likelihood of successful relactation and the rapidity of the onset of lactation. Basal prolactin levels and stimulation tests were of no additional predictive value. Each mother, regardless of milk production, expressed positive feelings about nurturing her infants in this manner. We conclude that relactation frequently is possible and may offer the mother of a sick or premature infant who desires to breast-feed an alternative if she does not maintain lactation in the immediate postpartum period.     

Post-discharge nutrition for the preterm infant

Newly designed, 'enriched,' formulas are now available for the formula feeding premature infant after hospital discharge. These new formulations add to the array of milks from which to choose when the discharge of the premature infant is approaching. However, the data to support optimal or reference nutrient intakes to use for the premature infant in the post-discharge are lacking. Breastfeeding should be encouraged as its beneficial effects may be related to the duration in which it is fed. Infants at risk for growth failure in the post-discharge period, such as infants unable to consume ad libitum intakes of milk, and who already have growth faltering or abnormal nutritional indices, may benefit for the addition of enriched formula. This review summarizes the recent data and comments on recommendations on post-discharge nutrition for premature infants.     

Knowledge, attitudes and practice regarding infant feeding among mother substitutes

With more women entering the workforce, the issue of infant nutrition has become more complex. Mother surrogates, or substitutes, are increasingly taking over the responsibility of infant care. 80 mother substitutes, aged 7-70, were interviewed in Jabalpur town, India, from October 1983-July 1984. Substitutes originated from nuclear families consisting of grandmothers, aunts, elder sisters, brothers, and servants. They were questioned concerning breast feeding, top milk initiation, feeding technique, and weaning. Results pointed to a variety of opinions on feeding practices and nutrition. 50% of younger mother substitutes and the majority of older, uneducated ones believed in initiating breast feeding from the 2nd day onward. 50% of young and 64% of older substitutes did not consider giving colostrum, and various reasons why are cited. 20% of all and 42% of highly educated substitutes were aware of the advantages of breast feeding. 65% of young and 60% uneducated did not know age of initiation of top milk. 45% advocated bottle feeding, with 25% preferring spoon feeding. With regard to "tinned milk" 40% did not use it, 25% were unaware of it, and of 30% using tinned milk, only 1/3 knew the correct technique of reconstitution. The majority of young and uneducated substitutes thought proper weaning age to be after 6 months. 50%, aged 21-40 years, believed in adding solid food from below 6 months. 90% of the young mother substitutes were against solids being introduced by the age of 4 months. A majority of the substitutes suggested weaning foods such as dal, rice, roti, and biscuits with a few considering tinned cereals as proper weaning foods. This response may point to the reason why protein and energy deficiency may be observed around weaning age in many infants throughout the 3rd world.     

A cohort study of term infants from Vilnius, Lithuania: feeding patterns

AIM: To present infant feeding patterns and to relate these to selected biological and social factors. METHODS: One hundred and ninety-two infants born at four delivery departments were followed prospectively from birth to 12 mo of age. Their parents were asked to tick weekly if the infant received items on a list of the most common infant foods and drinks, including breast milk. RESULTS: All infants started breastfeeding. Median duration of exclusive breastfeeding was 0.5 mo, and 3.75 mo for "any breastfeeding". Mothers who were older (>25 y), better educated (>11 y) and non-smokers breastfed significantly longer (median 4 mo). Median introduction of cow's milk was 8 (range 2-12) mo. At the age of 12 mo, 78% of infants received cow's milk and 58% of infants received cow's milk as the sole source of milk. Mothers who were younger (<21 y) and less educated (<12 y) introduced cow's milk significantly earlier. Mean (SD) start of solids was 3.4 (1.0) mo. Longer duration of breastfeeding was the only factor significantly associated with the later start of solids. Ninety-two percent of infants were introduced to fresh cheese before 12 mo. Additional liquids were widely given both to breastfed and non-breastfed infants. CONCLUSIONS: Compliance with the current infant feeding recommendations is not sufficient. Breastfeeding rates are low. Use of high-protein products is widespread. More effort should be made to educate young, less educated and smoking mothers.     

“Breastfeeding” without baby: A longitudinal,qualitative investigation of how mothers perceive,feel about,and practice human milk expression

Most American mothers who produce human milk (HM) now pump in place of some or all feeding at the breast, and most American infants are now fed pumped HM. We aimed to investigate mothers' perceptions of, attitudes toward, and practices for pumping and providing pumped HM. Results related to pumping are reported here. We conducted in‐depth, semi‐structured interviews among a diverse sample of 20 mothers who pumped, following each from pregnancy through infant HM‐feeding cessation up to 1 year postpartum. Data were analyzed using thematic analysis with Atlas.ti. Mothers' reasons for pumping changed over time and reflected their needs and desires (e.g., latch difficulty, return to work, and increasing their milk supply). Mothers reported that pump type and quality were important to pumping success and that pumping was time‐consuming, costly, and unpleasant compared to feeding at the breast. Regardless of how often mothers pumped, most felt pumping was necessary to meet their infant HM‐feeding goals and was a welcome means of sharing with other caregivers the bonding opportunity and tasks they associated with feeding infants. Mothers interpreted output from pumping sessions to understand their ability to provide enough milk to meet their infants' needs. Mothers' reasons for pumping may signal constraints to infant HM feeding that may be addressed with policy changes. Mothers' attitudes and perceptions toward pumping indicate that, although pumping fills important and welcome roles for many mothers, the reality of its practice may make it an unacceptable or infeasible substitute for some.     

Enteral nutrition for premature infants: the role of human milk

Nutrition support of the premature infant must be designed to compensate for metabolic and gastrointestinal immaturity, immunologic insufficiency, and the demands of associated medical conditions. The beneficial effects of human milk extend to the feeding of premature infants. Although human milk enhances immunity, nutritional concerns arise because the milk might not meet the expanded nutrient requirements of very low birth weight premature infants. Human milk fortifiers are available to provide optimum nutrition. This chapter summarizes the benefits and limitations of human milk for the premature infant.     

Decreasing retinol and α-tocopherol concentrations in human milk and infant formula using varied bottle systems

Expressing human milk has become a more common alternative for mothers, as the average work demand has increased. As more mothers must work, bottle feeding trends are increasingly common. The handling and storage of human milk introduce the risk of degradation to expressed human milk and infant formula. In following a 20-minute simulated feeding, Vitamin C has been found to degrade. Vitamin C acts as an anti-oxidant and is responsible for shielding other nutrients from oxidation, such as retinol and alpha-tocopherol. By analyzing a 20-minute simulated feeding, retinol and alpha-tocopherol each displayed decreases over time significantly different than that of the Control, which was milk not exposed to bottle feeding. In human milk, retinol showed as high as a 9.5% decrease compared to the Control. Similar trends were seen with the infant formula samples. The correlation between degradation and bottle feeding systems was dependent upon the formation of bubbles in the milk as the milk was removed from the bottle. The analysis indicated a decrease of up to 12%, as seen in retinol, and 35%, as seen in alpha-tocopherol. These decreases in retinol and alpha-tocopherol should be considered when using a bottle feeding system to deliver either human milk or formula to an infant. More research is necessary to determine the effect of this decrease on the nutritional status of infants, particularly premature infants, who are at higher risk for nutrient deficiencies.     

What every nurse needs to know about breast pumping: instructing and supporting mothers of premature infants in the NICU

Research has established that breast milk is the best source of nutrition for the premature infant. Because the infant is born prematurely, the mother will need support in expressing breast milk for her infant's use. The clinical nurse has the opportunity to educate the mother on the importance of breast milk for the premature infant and to support the mother through the course of pumping. However, many nurses are not sufficiently educated in the physiology of lactation to adequately support the mother. The purpose of this article is to educate the bedside nurse in the physiology of lactation so that the mother is adequately assisted in expressing breast milk for her vulnerable infant.     

Enteral feeding in the preterm infant

In planning enteral feeding in the preterm infant, decisions need to be made regarding the feeding schedule, choice of milk, and the route of administration. Feeds should be commenced within a week after birth beginning with subnutritional quantities. Preterm human milk from the infant's own mother is the milk of choice. When full enteral feeding is established, supplementation with human milk fortifier is recommended. Donor human milk and preterm formula are alternatives. Early establishment of enteral nutrition and maintenance of optimal nutrition during infancy are important as dietary manipulations in preterm infants have potential long-term influences on their health, growth and neurodevelopment.     

Zufüttern im Krankenhaus beim gestillten reifen Neugeborenen und sp?ten Frühgeborenen

Breastfeeding or rather breast milk is the most complete form of nutrition for infants, with a range of benefits for health, growth, immunity, and development. Postpartum mothers should receive maximum support from the caregiving team to enhance the ability to breastfeed their newborn infants. Exclusive breastfeeding is the adequate nutrition for most of the healthy term infants during their first days of life and later on. In only a few conditions is supplemental feeding appropriate and medically indicated. The American Academy of Breastfeeding Medicine defined feasible position papers giving consideration to the “Baby-Friendly Hospital Initiative” by the WHO, establishing the circumstances in which supplemental feeding is indicated. If supplemental feeding is necessary, expressed milk from the infant’s own mother or pasteurized donor milk should be the first choice. If human milk is not available, artificial supplements like nutrient solutions, maltodextrin, or formulas should be used. Even for late preterm infants breast milk is the first choice of nutrition in the first days of life and later on. They have special nutritional needs and increased risk of medical problems and should therefore receive more attention.     

Spoonfeeding is associated with increased infant weight but only amongst formula‐fed infants

Infant feeding experiences are important for the development of healthy weight gain trajectories. Evidence surrounding milk feeding and timing of introduction to solids is extensive; however, the impact of the method of introducing solids on infant growth has been relatively underexplored. Baby‐led weaning (where infants self‐feed family foods) is proposed to improve appetite regulation, leading to healthier weight gain and a reduced risk of obesity. However, the evidence is mixed and has methodological inconsistencies. Furthermore, despite milk being a large part of the infant diet during the period infants are introduced to solid foods, its influence and interaction with introductory style have not been considered. The aim of this study was to explore growth among infants aged 3–12 months according to both style of introduction to solid foods and milk feeding; 269 infants were weighed and measured, and body mass index (BMI) computed. The results showed that overall, infants who were spoon‐fed (compared with self‐fed) at introduction to complementary feeding (CF) had greater length (but not weight or BMI). However, when milk feeding was accounted for, we found that infants who were both spoon‐fed and fully formula fed had greater weight compared with spoon‐fed, breastfed infants. There was no significant difference in weight among self‐fed infants who were breastfed or formula fed. The results highlight the importance of considering infant feeding as a multicomponent experience in relation to growth, combining both milk feeding and method of CF. This relationship may be explained by differences in maternal feeding style or diet consumed.     

Feeding strategies for premature infants: randomized trial of gastrointestinal priming and tube-feeding method

BACKGROUND: Data on enteral feeding management of premature infants are limited and often not the subject of randomized clinical trials. Several small studies suggest benefits from the early initiation of feeding, but do not assess the combined effects of time of initiation of feeding, tube-feeding method, and type of milk used. Either singly or in combination, these treatments may affect growth, bone mineralization, biochemical measures of nutritional status, and feeding tolerance, and, ultimately, the duration of hospitalization. METHODS: A total of 171 premature infants, stratified by gestational age (26 to 30 weeks) and diet (human milk or preterm formula) were assigned randomly among four treatment combinations in a balanced two-way design comparing the presence or absence of gastrointestinal (GI) priming for 10 days and continuous infusion versus intermittent bolus tube-feeding. RESULTS: The major outcome, time required for infants to attain full oral feeding, was similar among treatments. GI priming was not associated with any measured adverse effect and was associated with better calcium and phosphorus retention, higher serum calcium and alkaline phosphatase activity, and shorter intestinal transit times. The bolus tube-feeding method was associated with significantly less feeding intolerance and greater rate of weight gain than the continuous method. In addition, the greater the quantity of human milk fed, the lower the morbidity. CONCLUSIONS: Early GI priming with human milk, using the bolus tube-feeding method, may provide the best advantage for the premature infant.     

Infant formula and toddler milk marketing and caregiver's provision to young children

The World Health Organization International Code of Marketing of Breast‐milk Substitutes prohibits claims and other marketing that may confuse caregivers about benefits of formula and other milk‐based drinks for infants and toddlers, but such marketing is common in the United States. This study assessed caregivers' provision of milk‐based products to their infants and toddlers and potential confusion about product benefits and appropriate use. Online survey of 1,645 U.S. caregivers of infants (6–11 months) and toddlers (12–36 months). Respondents identified infant formula and toddler milk products they served their child (ren) and provided relative agreement with common marketing claims. Logistic regression assessed relationships between agreement and serving these products, controlling for individual characteristics. Over one‐half of caregivers of infants (52%) agreed that infant formula can be better for babies' digestion and brain development than breastmilk, and 62% agreed it can provide nutrition not present in breastmilk. Most caregivers of toddlers (60%) agreed that toddler milks provide nutrition toddlers do not get from other foods. Some caregivers of infants (11%) reported serving toddler milk to their child most often. Agreement with marketing claims increased the odds of serving infant formula and/or toddler milks. For caregivers of toddlers, odds were higher for college‐educated and lower for non‐Hispanic White caregivers. Common marketing messages promoting infant formula and toddler milks may mislead caregivers about benefits and appropriateness of serving to young children. These findings support calls for public health policies and increased regulation of infant formula and toddler milks.     

Human milk supplementation for preterm infants

Nutrition support of the premature infant must be designed to compensate for metabolic and gastrointestinal immaturity, immunologic compromise, and associated medical conditions. The beneficial effects of human milk extend to the feeding of premature infants. However, nutritional concerns arise because the quantity of nutrients in human milk may not meet the great nutrient needs of the premature infant born weighing less than 1500 g. Human milk fortifiers are available to provide optimum nutrition. This review summarizes the benefits and limitations of human milk for the premature infant.     

Human milk supplementation for preterm infants

Nutrition support of the premature infant must be designed to compensate for metabolic and gastrointestinal immaturity, immunologic compromise, and associated medical conditions. The beneficial effects of human milk extend to the feeding of premature infants. However, nutritional concerns arise because the quantity of nutrients in human milk may not meet the great nutrient needs of the premature infant born weighing less than 1500 g. Human milk fortifiers are available to provide optimum nutrition. This review summarizes the benefits and limitations of human milk for the premature infant.     

Benefits of maternal and donor human milk for premature infants

Nutrition support of the premature infant must be designed to compensate for metabolic and gastrointestinal immaturity, immunologic insufficiency, and the demands of associated medical conditions. The beneficial effects of human milk extend to the feeding of premature infants. While human milk enhances immunity, nutritional concerns arise because the milk may not meet the expanded nutrient requirements of the very low birth weight (VLBW, less than 1500 g) premature infant. Human milk fortifiers are available to provide optimum nutrition. This review summarizes the benefits and limitations of human milk for the premature infant.